You have to be careful what you say around children. Their minds are like sponges, absorbing the world around them, even though at times it may seem difficult to get their attention. The other day I was trying to get Oakley’s attention and after several attempts he said, “Wait a minute.” He emphasized his point by raising his index finger and slightly nodding his head. Where did that come from? I asked
myself. His phrasing and mannerism were so much like an adult’s.
Language is complex and operates on many levels. Children are often very literal and have yet to develop nuanced speech such as using idioms. The latter are metaphors (comparisons) whose original meanings have been lost in the sands of time. An example is, “It’s raining cats and dogs.” Try explaining that phrase to a child. We adults understand the phrase beyond the verbiage. The meaning originated with thatched roofs that leaked in a hard rain driving dogs and cats from their their cozy perches in the rafters.
When my girls were little, a guy in my Sunday school class would often ask my older daughter, Emily, if she was, “worth a dern.” This totally flumuxed Emily who didn’t know how to answer the question. I explained the question to her and we practiced and practiced her response. The next time the jokester asked the question, she triumphantly said, “Yes, and a whole lot more!”
An essay that appeared in the Journal of the American Medical Association (JAMA) entitled “The $50,000 Physical,” challenged me to rethink the notion of an annual physical examination. The essay described a “healthy” elderly man who saw his internist for an annual examination. The internist performed some seemingly reasonable tests, but when abnormalities were discovered a series of more invasive tests resulted, culminating in a liver biopsy, internal bleeding, ten units of blood and a $50,000 bill. Incidentally, the liver biopsy showed a benign nodule/lump.
I’ve written previously about the intangible benefits of an annual examination such as renewing the relationship with your doctor. My wife, Becky, taught me that all of life is about relationships. It is ill advised that your doctor does not “know” you. There is far more to each of us than our blood pressure readings or cholesterol number. Furthermore, I believe care can only be rendered by a caring doctor who knows his patient.
There are also tangible aspects of an annual examination including updates of medical problems discovered by other doctors, reviewing medications, updating vaccinations and discussing screening tests such as mammography or colonoscopy.
While it is true that the collection of such medical information need not be done by your internist, I believe too much patient care is being delegated to what are called physician extenders (nurse practitioners and physicians assistants). In fact, an entire “cottage industry” of data collection has arisen in recent years called the “annual wellness visit,” which then bills Medicare for the data collection visit formerly done by the doctor as part of the annual exam. I felt that this was a wasteful process and a chief factor in driving me from my traditional medical practice.
You might be surprised to learn that there has never been a study to test whether an annual examination is “worth a dern.” The notion of a preventive health examination, where problems might be discovered early and more treatable, originated with the New York Metropolitan Life insurance company in the late 1800s. During my forty year career I’ve seen “the good, the bad and the ugly.” I’ve seen posh resorts which do executive physicals on VIPs. And I’ve see the other extreme where there’s virtually no care.
Perhaps the government is well-intentioned by insisting on annual wellness visits and data collection. These days I doubt the government’s sincerity and its competence. Like most things a balance needs to be struck. In a January 9, 2015 column in the New York Times a respected doctor advised that it was time to “Skip Your Annual Physical.” This position was quickly challenged in the March 2015 medical journal, Consultant. And the debate goes on.
While it is true that I don’t often find major issues on annual examinations of my patients, I can recall exams where I have found vascular disease before a heart attack or stroke occurred. Once, while treating a cold I found a kidney cancer before it spread. And during an annual examination I found a massively enlarged uterus missed by another physician’s cursory care. Happily, my newest patient just had his leaking aortic valve successfully replaced after I discovered that his heart murmur was far more serious than anyone imagined.
So what kind of conclusions can we make and where do we go from here? A personal relationship with your physician is of paramount importance. You must never be a stranger to your doctor. Institutionalized data gathering has the promise of improving care, but there are no studies to show that it works. Furthermore, wellness visits and electronic medical records are fabulously expensive and place
huge additional burdens on doctors and nurses. Neither have been documented to improve patient care.
Twenty year olds probably don’t need annual exams, but older folks do. And lastly, you and your doctor should be the ones who determine whether check-ups or comprehensive exams are best for you. By necessity, the government motives are driven by herd management and expense rather than the tailored care a child of God deserves.
